SHAHV Membership Application
SPEECH - LANGUAGE AND HEARING ASSOCIATION
OF THE HUDSON VALLEY
PO Box 536
Millerton NY 12546 
January 1  -  December 31

Check here if there are no changes to your personal information. _____

Name: _____________________________________________________________________  
            First                                           Last
  Please print your name as you would like it to appear in the membership directory.

Mailing Address: ______________________________________________________________

___________________________________________________________________________

Home Phone: _______________________ Business Phone:  ____________________________

Email address: ________________________________________________________________
                         Used for SHAHV communication purposes only.

The SHAHV Membership Directory is available to SHAHV members only.  CHECK HERE IF YOU DO NOT WANT YOUR INFORMATION LISTED IN THE MEMBERSHIP DIRECTORY. _________

Place of Employment: ____________________________ _____________________________

Primary ages of Clients: ______________________   Work Site: ________________________
                                    (EI, PreS, Elem, Adults)            (Homes, School, Hospital)

Certification/license
(Circle all that apply)

ASHA
CCC-SLP
CCC-A    

NYS Licensure
Speech Pathology
Audiology

NYS Certification
TSHH/TSSLD                       Perm Prov
Teacher of the Deaf                Perm Prov

Professional Affiliations:  ASHA Special Interest Div #       AAA      NYSSLHA      NSSLHA         

 _________Member $35               ______Associates/Student Member $10
             
Please check made payable to SHAHV and mail to SHAHV, PO Box 536, Millerton NY 12546

For office use only:    CHECK #______    CHECK DATE#___________   Amount: ____________  
                                       

____YES, I am available to help on a committee!!


___Legislative Committee: Assists the Past President in organizing Lobby Day and other legislative activities.

___Program Committee: Assists the Vice President in organizing workshops and monthly meeting activities.

___Membership Committee: Assists the Secretary in membership recruitment and membership drives.

___Public Information Committee:
        Assists the Treasurer in organizing public relations and “May is Better Hearing and Speech Month” activities.

___Newsletter Committee: Assists the Newsletter Editor in the development and distribution of the newsletter.